What to Know About Identifying and Managing Alopecia in Skin of Color, with Ginette Okoye, MD

Hair loss among individuals with skin of color may present unique diagnostic and therapeutic challenges for some healthcare providers, resulting from variations in clinical presentation, hair biology, and cultural considerations.

During the 2025 SDPA Annual Summer Dermatology Conference in Washington, DC, Ginette Okoye, MD, highlighted some of the most common types of alopecia commonly observed in those with skin of color, including traction alopecia, central centrifugal cicatricial alopecia (CCCA), frontal fibrosing alopecia, and androgenetic alopecia. Okoye is known for her work as a professor and chair of dermatology at Howard University College of Medicine.

During the talk, titled ‘Textured Hair, Tailored Care: Managing Alopecia in Skin of Color,’ Okoye emphasized ways to distinguish scarring from non-scarring alopecias, along with the selection of the appropriate diagnostic techniques, such as biopsies. Okoye even discussed the evolutionary origins of hair and what makes the different subtypes of hair shaped the way they are.

“The cuticle is the same in terms of its composition in all hair groups, but the number of layers of cuticular cells actually differs,” Okoye explained. “People with Asian type hair have more cuticular layers, and people with African-type hair have the fewest cuticular layers. So we believe that that may contribute to the higher prevalence of hair breakage in people with African-type hair, very curly hair.”

Okoye highlighted the different styling techniques and cultural variations that appear among Black patients as well as others. She later discussed the different variations of alopecia, noting that certain types can impact patients with skin of color more.

“Whenever I think of alopecia, I was taught to think about scarring alopecia and non-scarring alopecia and to always make that kind of distinction in my head when I see a patient,” Okoye said. “That's the first thing I'm looking for. Are the follicles there, or are they gone? Have they been replaced with fibrosis? I listed the most common types of alopecia here. The ones that have a red asterisk are the ones that are more common in patients with skin of color.”

Okoye explored variations in traction alopecia, CCCA, frontal fibrosing alopecia, and androgenetic alopecia, noting several helpful facts about these subtypes. She expressed that although frontal fibrosis alopecia is not more common in patients with skin of color, it is often misdiagnosed as traction alopecia. Okoye stressed that frontal fibrosing alopecia, a scarring alopecia, is often misdiagnosed as traction alopecia in Black women.

“Traction is caused by any chronic culling force on the hair follicles, and it's usually non-scarring and temporary if it's caught early and that traction is reduced,” Okoye explained. “But it can be prolonged in some cases. One of the classic findings in traction, of course, is that it’s usually on the hairline, but patients usually have a fringe of normal hair, let's call them ‘baby hairs,’ along the frontal hairline. It's called the fringe sign, which you can see in this patient here. Even though traction alopecia is often associated with African American women, due to some of the hair styling practices that we employ, traction can occur in anyone who is having that chronic pulling force for chronic pressure. Often, people who use religious headwear, a hijab or turban, if it's in the same place every day, may develop traction alopecia as well.”

Okoye stressed that biopsies may be highly beneficial in the diagnosis of different alopecia subtypes, highlighting that it can even be ‘therapeutic’ in some patients, given patients’ feelings that their conditions may be impermanent or even imagined. She described ways to address types of alopecia, such as traction alopecia.

“Topical steroids twice a day for a couple of weeks, and then 2 to 3 times a week for a couple of months,” Okoye recommended. “That’s usually what I would do, but I don't usually use really strong topical steroids. In this situation, I would like either fluocinolone acetonide oil, fluocinolone solution, or try an ointment. I give three different vehicles, ointment, oil, and solution, because I always want to have a chat with the patient about which vehicle they prefer…Oils are also pretty well-liked. But if someone is wearing a straight hairstyle, even if they have curly hair, if they're wearing a straight hairstyle, sometimes a solution is a better choice, because it won't weigh the hair down. So don't make that decision for the patient. Just give them the options.”

Okoye discussed frontal fibrosing alopecia as well, noting that the condition is a type of lichen planopilarus and a lymphocytic scarring alopecia. Patients develop this peri-follicular erythema and perifollicular scale, and Okoye highlighted that it can move pretty quickly compared to CCCA. She noted that CCCA is slower and insidious.

“LPP and [frontal fibrosing alopecia] patients can be permanently bald in weeks,” Okoye said. “So if you see this, you have to act and you have to act quickly…If you're not sure if this is traction or frontal fibrosing alopecia, there are some clues you can look for. The first is facial papules. Hopefully, you can see it projects well. The papules can be pretty subtle, but they usually have skin-colored facial papules, sometimes a little shiny on the lateral sides of the face. Many patients will have hyperpigmentation on the face, which is called lichen planus pigmentosis…You're looking for non-scalp hair loss, which usually has preceded the scalp hair loss, sometimes by many, many years. The first thing patients tend to lose is the hair on their arms, their forearms, and on their legs.”

Okoye sought to provide attendees with practical strategies to improve outcomes and build trust with diverse patient communities. The psychosocial effects of hair loss in those with skin of color require cultural sensitivity and competency. With these ideas in mind, evidence-based approaches and emerging therapies can be implemented in individualized care plans for diverse patient populations.

For any additional information on this topic or related topics covered at the 2025 SDPA Conference, view the latest conference coverage.

The quotes contained in this session summary were edited for clarity.